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within 3 minutes to provide advanced life support. The cardiac pulmonary hypertension, and cyanosis; agitation, altered
monitor displayed ventricular tachycardia. No pulse was mentation, encephalopathy, seizures, and coma; coagulop-
palpable, so the patient was defibrillated. With CPR in progress, athy and diffuse bleeding; tachycardia, bradycardia, dys-
the woman was endotracheally intubated and given 1 mg IV rhythmias, fetal or maternal hypotension, fetal heart rate
epinephrine. These interventions produced a palpable pulse. abnormalities, and cardiovascular collapse. 1,2,4,6 Blood tests
Chest compressions were discontinued, and endotracheal tube (electrolytes, type and crossmatch, whole blood count, and
placement was radiographically confirmed. The patient’s blood coagulation studies), chest radiography, electrocardiogra-
pressure was maintained at 90/50 mm Hg with the aid of phy, and echocardiography all facilitate patient manage-
continuous infusion of epinephrine. Her heart rate was 120/ ment, 1 but there are no laboratory or imaging studies
min, and oxygen saturation was greater than 95%. Vaginal and specific to AFE. Diagnosis is based on patient history and
surgical-site bleeding were noted. Potential causes for this examination, after eliminating other possible conditions.
cardiac arrest were considered, and pulmonary embolism was Autopsy may be required for a definitive diagnosis.
strongly suspected. A decision was made to transfer the woman Likewise, no AFE preventative measures exist. Treat-
to a tertiary medical facility for further care. While the transfer ment of AFE involves supportive care only, including
was being arranged, she experienced another cardiac arrest and endotracheal intubation and mechanical ventilation for
developed disseminated intravascular coagulopathy (DIC). airway management and oxygenation, vasopressors to
Despite extensive resuscitation efforts, this new mother was support blood pressure, and blood component therapy to
pronounced dead 4 hours later. reverse coagulopathies. 1,6–8 Other interventions, —such as
Amniotic fluid embolus (AFE), also known as anaphylac- exchange transfusion, extracorporeal membrane oxygena-
toid syndrome of pregnancy, is an obstetric emergency that tion, administration of hydrocortisone or recombinant
requires immediate life-saving interventions. 1–4 First described factor VIIa, and uterine artery embolization—have been
in 1926, AFE was not recognized as a disease process until reported with mixed results. 2,6,8 Careful attention to a
1941. 1,2 AFE is a rare disorder affecting only 0.8 to 6.1 cases pregnant patient’s medical history, risk factors, and
per 100,000 deliveries. 1,3–6 The true incidence is difficult to presentation of symptoms facilitate early recognition of
determine, owing to varying definitions of AFE, inconsistent AFE and rapid intervention. Nevertheless, as in this
research methodologies, and underdiagnosis. 5 Case fatality patient’s case, AFE is unpredictable, onset is sudden, and
estimates range from 13% to 86%. 1,3,5,7,8 Strict adherence to the outcome is usually fatal.
AFE signs and symptoms, as described in recent studies, place
maternal mortality at about 60%. 6 Neonatal outcomes are also Acknowledgment
poor if onset of AFE occurs prior to delivery. Even when
recognized early, fetal mortality is 65%. 1–3 We thank Gretchen K. Carroll, EdD, JD, SHRM-SCP, for
Although AFE presents much like other acute embolic her critical review of this article.
events, the condition is precipitated by maternal circulatory
system contact with amniotic fluid or fetal debris. This contact
causes an anaphylactoid (anaphylaxis-like) response producing
shock, DIC, and death. 1,2 It is not unusual for amniotic fluid REFERENCES
or fetal debris to enter maternal circulation, but most pregnant 1. Kaur K, Bhardwaj M, Kumar P, Singhal S, Singh T, Hooda S. Amniotic
women will not experience this profound reaction. AFE fluid embolism. J Anaesthesiol Clin Pharmacol. 2016;32:153-159.
consists of 2 phases. The early phase involves acute respiratory 2. Gist RS, Stafford IP, Leibowitz AB, Beilin Y. Amniotic fluid embolism.
failure and cardiac arrest. If the patient survives these events, the Anesth Analg. 2009;108:1599-1602.
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identified or hypothesized, including abdominal trauma, 4. Mayo Foundation for Medical Education and Research. Amniotic fluid
advanced maternal age, cervical lacerations, cesarean section, embolism. http://www.mayoclinic.org/diseases-conditions/amniotic-fluid-
early placental separation, eclampsia, induced labor, intense embolism/basics/definition/con-20035462. Published September 11,
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Clinical findings associated with AFE include sudden Med J. 2012:2-7.
onset of chills, cough, dyspnea, pulmonary edema, acute 6. Clark SL. Amniotic fluid embolism. Obstet Gynecol. 2014;123(2):337-348.
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